Endoscopic Mucosal Resection in the Stomach Using the Insulated-Tip Needle-Knife

Objectives and Basic Principles

Endoscopic mucosal resection (EMR) is now accepted as a standard treatment for intramucosal gastric cancer in Japan. Since Tada et al. described the strip biopsy method in 1983 [1], this technique has been widely used not only in Japan but also in other countries and has been improved in a variety of ways [2]. According to the guidelines for the treatment of gastric cancer from by the Japanese Gastric Cancer Association, the indications for EMR are: intramucosal cancer; a diameter of 20 mm or less; intestinal type, histologically; and no findings of ulcer. However, with conventional techniques such as the strip biopsy method, it is difficult to obtain a large specimen as a ”one-piece” or ”en bloc” resection.

The most important issue in curing cancer is achieving a complete resection. ”Multi-fragment” or piecemeal resection makes it difficult to histologically evaluate the completeness of the resection, which can occasionally result in incomplete treatment leading to local tumor recurrence. Therefore, en bloc resection with an adequate margin that has no tumor cells (i. e. that is tumor cell-negative) is ideal for successful treatment.

In 1988 Hirao et al. developed another EMR technique for en bloc resection, using the electrosurgical needle-knife, that is, endoscopic resection with local injection of hypertonic saline-epinephrine solution for hemostasis [3]. This technique increased the rate of curative resection remarkably; however, the cutting power required for mucosal incision (150 W) is so great that perforation is likely to occur if there is not a high degree of skill on the part of the clinician. In order to overcome the above disadvantage, Hosokawa developed a new needle-knife, i. e. the insulated-tip diathermic electrosurgical knife, which has a ceramic ball at the top of the incising needle to prevent electrical leakage toward the deeper layer of the stomach [4]. Experimentation with a pig’s stomach showed that the insulated-tip knife resected only the mucosa and submucosa without histologically evident burning effects in the serosa, and it was successfully used to resect dog gastric mucosa in vivo. After these promising experimental results in animal models, in 1994 Hosokawa introduced the use of the device in the clinic at the National Cancer Centre Hospital East (NCCHE), Chiba, Japan [4]. Ohkuwa et al. were the first to report the efficacy and complications of EMR using the insulated-tip knife for intramucosal gastric neoplasms [5]. Miyamoto et al. reported on the feasibility of EMR with the insulated-tip knife as a standard technique in clinical practice [6].

References

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